Joining time of internal control system: 2009-116 1 6: 45: 56 Click:161Chapter I General Provisions Article 1 is to strengthen and standardize the administrative law enforcement work of medical insurance agencies and improve the level of administrative law enforcement. Article 2 Under the authorization of the Labor Law, the Provisional Regulations on the Collection and Payment of Social Insurance Fees and other laws and regulations, medical insurance agencies have law enforcement functions such as revenue and expenditure, management and operation of medical insurance funds. Article 3 The term "administrative law enforcement" as mentioned in these Rules refers to the specific administrative acts carried out by medical insurance agencies and their staff in accordance with the statutory authority and procedures for the implementation of laws, regulations and rules. Specifically, it includes: administrative confirmation of various medical insurance enrollment registration and medical insurance base verification, administrative collection of medical insurance premiums, administrative payment of various medical insurance benefits, audit of medical insurance enrollment, payment and payment of medical insurance benefits, and audit of lower medical insurance institutions by higher medical insurance institutions. Article 4 The basis of administrative law enforcement of medical insurance agencies is: People's Republic of China (PRC) Labor Law, People's Republic of China (PRC) Audit Law, Provisional Regulations on the Collection and Payment of Social Insurance Fees, the State Council's Decision on Establishing the Basic Medical Insurance System for Urban Workers and other laws and regulations, Interim Measures for the Administration of Social Insurance Registration, Interim Measures for the Administration of Social Insurance Fees Declaration and Payment, and Interim Measures for the Administration of Social Insurance Fees Collection and Payment. Article 5 Medical insurance agencies shall, under the authorization of laws and regulations, implement administrative law enforcement in their own names. Article 6 The administrative department of labor and social security shall, in accordance with the provisions of laws, regulations and rules, entrust the medical insurance agency to implement administrative law enforcement in the name of the administrative department of labor and social security within the statutory authority. Seventh on-site law enforcement personnel must be the staff of medical insurance agencies, and shall not be less than two. Law enforcement officers should take the initiative to produce administrative law enforcement certificates or entrusted administrative law enforcement certificates or social insurance inspection certificates and other law enforcement qualification certificates. Law enforcement personnel should implement the avoidance system in law enforcement. Article 8 The administrative law enforcement of medical insurance shall adhere to the principles of openness, fairness and impartiality, accept applications from citizens, legal persons and other organizations in a timely manner, investigate and deal with all kinds of illegal cases of medical insurance according to law, and earnestly safeguard the legitimate rights and interests of administrative counterparts. Article 9 When implementing administrative law enforcement, if it is found that the provisions of the subordinate effect conflict with those of the superior effect, the provisions of the superior effect shall be implemented; When it is found that the new regulations formulated by the same organ are in conflict with the old regulations or the special regulations are in conflict with the general provisions, the new regulations or special regulations shall be implemented. Article 10 The medical insurance agency shall promptly hand over the problems that should be investigated and dealt with by the relevant functional departments in the performance of administrative law enforcement functions, and submit them to the administrative departments of labor and social security, price, health and drug supervision that have the power to punish them. Article 11 Decisions made by medical insurance agencies to perform administrative law enforcement functions shall be delivered to the parties concerned in time, forming a "Receipt of Delivery" (see Annex 1) or other delivery vouchers. Twelfth medical insurance agencies to make specific administrative acts, should inform the parties have the right to apply for administrative reconsideration, administrative reconsideration, administrative litigation and the application period. Citizens, legal persons or other organizations have the right to make statements and defend specific administrative acts made by medical insurance agencies; If a specific administrative act of a medical insurance agency infringes upon its legitimate rights and interests, it shall have the right to apply for administrative reconsideration, administrative reconsideration or bring an administrative lawsuit according to law. Chapter II Administrative Confirmation of Medical Insurance Article 13 Administrative confirmation of medical insurance refers to the specific administrative act of medical insurance agencies to confirm, identify, prove and publish the medical insurance qualifications and medical insurance base of insured units and insured persons according to law. Article 14 According to the provisions of relevant laws, regulations, rules and normative documents, all units and individuals who should participate in urban medical insurance should fill in the Registration Form of Basic Information of Urban Medical Insurance Units in Nanchong City (see Annex 2) and the Registration Form of Personal Basic Information of Urban Medical Insurance in Nanchong City (see Annex 3) within the prescribed registration time, and go through the medical insurance registration formalities at the medical insurance agency. Fifteenth medical insurance agencies shall immediately accept the medical insurance information registration form, certificates and materials provided by the payer. After the preliminary examination, if it is necessary to verify the relevant information, two or more staff members shall be assigned to conduct on-site verification and form a verification report. Sixteenth medical insurance agencies should complete the medical insurance registration review within 10 working days from the date of acceptance, and make a decision on whether to confirm. To meet the requirements of the registration application, issue social insurance registration certificate, medical insurance certificate (card) or other registration confirmation materials. For those who do not meet the requirements for registration, a notice of non-participation shall be issued (see Annex 4). Article 17 If the registered items of the insured units or individuals are changed or the insured units are terminated according to law, they should fill in the Registration Form for Information Change of the Insured Units (see Annex 5), the Registration Form for Information Change of the Insured Personnel (see Annex 6) and the Registration Form for Cancellation of the Insured Units (see Annex 7) within the specified time, and go through the formalities for changing or canceling the medical insurance registration at the medical insurance agency. The medical insurance agency shall immediately review and confirm the submitted application and other materials; For those who cannot be immediately examined and confirmed, the examination and confirmation shall be completed within 2 days from the date of receiving the application and other materials at the longest. Article 18 The insured unit or individual shall apply to the medical insurance agency for the declaration of the medical insurance base (calculation of payment base and personal account base) within the specified time, and submit the medical insurance base declaration form (see Annex 8), detailed information of withholding and remittance and other information specified by the medical insurance agency. On-the-job employees shall declare the base number once a year in principle, and retired employees shall immediately declare the base number to the medical insurance agency after going through the retirement formalities or adjusting the retirement fee. Nineteenth medical insurance agencies shall immediately review the base declaration form and related materials submitted by the insured units or individuals. If it cannot be reviewed immediately, the review shall be completed within 2 days from the date of receiving the materials such as the base declaration. If the application materials are complete and the base is true, it shall be signed for approval; Put forward audit opinions on the declaration that does not meet the requirements, and return it to the reporting unit for revision and re-audit. Article 20 If the applicant's Application Form for Medical Insurance Base still fails to meet the requirements after revision or the applicant refuses to re-declare, it shall serve the applicant with the Notice of No Access to Medical Insurance Base (see Annex 9), fill in the Proposal for Submitting Medical Insurance Review (see Annex 10), and submit it to the medical insurance review department for review according to the review procedures. Twenty-first medical insurance agencies to verify and confirm the medical insurance base, at the latest within 7 days from the date of receiving the application for the base and other materials, in the form of "Medical Insurance Base Verification Notice" (see annex 1 1) to the applicant. Chapter III Administrative Collection and Payment of Medical Insurance Article 22 Administrative collection and payment of medical insurance refers to the administrative act of medical insurance agencies to collect medical insurance funds from medical insurance insured units and individuals for free in accordance with relevant laws, regulations, rules and normative documents. Article 23 The medical insurance agency shall, according to the relevant laws, regulations, rules, normative documents and the approved base, prepare the monthly collection plan and issue the Notice of Payment of Medical Insurance Premium (see Annex 12) to inform the insured units and individuals of their rights according to law. Twenty-fourth insured units shall pay medical insurance premiums in full and on time after receiving the Notice of Payment of Medical Insurance Fees (the announcement of the time for medical insurance agencies to pay medical insurance premiums in their personal capacity shall be regarded as the issuance of the notice of payment). If the insured units and individuals fail to pay the medical insurance premium in full and on time, the medical insurance agency will issue the Medical Insurance Dunning Notice (see Annex 13) to urge them to pay the medical insurance premium in full within a time limit. Twenty-fifth insured units and individuals refused to pay medical insurance premiums, medical insurance agencies can apply to the labor and social security departments to issue a "labor and social security deadline correction instruction"; If it fails to pay within the time limit, the labor and social security department shall submit it to the people's court for compulsory execution according to law. In addition to making up the unpaid payment, a late payment fee of 2 ‰ will be charged on a daily basis from the date of default. Chapter iv administrative payment of medical insurance premiums article 26 administrative payment of medical insurance refers to the administrative act of medical insurance agencies to examine and determine the qualifications, project scope, standards and amount of medical insurance service charges of medical insurance insured units or insured persons, designated medical institutions and designated retail pharmacies and pay the fees according to relevant laws, regulations, rules and normative documents. Twenty-seventh insured hospitalization, should submit relevant information within 24 hours, go through the formalities of hospitalization registration; The medical insurance agency shall immediately review the submitted hospitalization registration materials. If it cannot be audited immediately, it shall be completed within 3 days from the date of receiving the hospitalization registration materials. Twenty-eighth insured during hospitalization special examination, special treatment, special medication need medical insurance fund settlement, it shall fill out the "special examination (treatment, medication) fee settlement application form", and report to the medical insurance agency within the specified time. The medical insurance agency shall immediately review the submitted materials. If the materials cannot be reviewed immediately, the review shall be completed within 3 days from the date of receiving the materials. Twenty-ninth medical insurance agencies should immediately audit the hospitalization expenses applied by individuals according to the audit standards. If the audit cannot be conducted immediately, it shall be completed within 2 days (postponed on holidays) from the date of receiving the information. Applications that meet the payment conditions shall be paid in full and on time according to the amount determined by the audit; For applications that do not meet the payment conditions, the medical insurance agency shall issue a notice of non-payment of medical expenses (see Annex 14). Thirtieth of the hospital registration audit, medical supervision, medical service supervision, personal declaration of hospitalization expenses found in the audit of the relevant information need further verification, medical insurance agencies shall assign two or more staff to verify, and after receiving the application materials 10 working days to complete the verification. In case of holidays or other special circumstances, with the approval of the legal representative of the medical insurance agency, it may be extended for 5 working days. During the verification, the inspectors shall collect evidence in accordance with the relevant provisions and evidence requirements in the administrative litigation, form an evidence chain and form a medical record summary (see annex 15), a medical insurance service supervision inquiry record (see annex 16), a medical insurance on-site verification record (see annex 17) and the first section of the investigation summary report (see annex 65438). The medical insurance agency shall immediately conduct a preliminary examination of the application, and if the preliminary examination cannot be completed immediately, it shall complete the examination within no more than 2 days (holidays postponed) from the date of receipt of the information, and timely and fully allocate the expenses according to the amount determined in the preliminary examination. Thirty-second medical insurance agencies shall, on the basis of preliminary examination, conduct a detailed examination of the fees applied by designated medical institutions and designated retail pharmacies, and truthfully fill out the Record Draft of Medical Expenses Examination. The medical insurance agency shall first issue the Notice of Non-payment of Medical Expenses (see Annex 19) and then issue the Notice of Non-payment of Medical Expenses (see Annex 20) after listening to the statements of the parties concerned, and deduct it from the next month's expenses. Chapter V Administrative Supervision and Inspection of Medical Insurance Article 33 The administrative supervision and inspection of medical insurance refers to the specific administrative act of medical insurance agencies to inspect and supervise the compliance of insured units, individuals and corresponding institutions within the management scope with relevant laws, regulations, rules and normative documents of medical insurance according to relevant laws, regulations and normative documents. Mainly medical insurance audit and medical insurance audit. Thirty-fourth medical insurance audit procedures in accordance with the "Nanchong medical insurance audit procedures" (Trial). Thirty-fifth medical insurance audit procedures shall be implemented in accordance with the Interim Measures for Internal Audit of Social Insurance Funds in Sichuan Province. Chapter VI Others Article 36 If any staff member of the medical insurance agency abuses his power, engages in malpractices for selfish ends or neglects his duty, which constitutes a crime, he shall be investigated for criminal responsibility according to law; If it does not constitute a crime, the responsible person shall be given administrative sanctions. Article 37 These Provisions shall be implemented as of June 65438+1October 65438+1October 2007. I hope it helps you.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.